The document describes the anatomy and clinical examination of the orbit. It discusses: 1. The structures that make up the orbit, including bones, nerves, vessels and muscles. 2. How to clinically examine the orbit, eyelids, eye movements and globe to assess for conditions like proptosis, dystopia, diplopia and optic nerve dysfunction. 3. Common orbital pathologies like thyroid eye disease, orbital cellulitis, cavernous sinus thrombosis and trauma and how they present on examination and are managed.

1. The Orbit
Mohamed Abdelzaher MD, FRCS

2. Pear-shaped
cavity, the
stalk of
which is the
optic canal

3. Dimensions
of the Orbit

4. Orbital Plate of Frontal Bone
Lesser Wing of Sphenoid Bone
• Front - Less
• Frontal Bone
• Lesser Wing
of Sphenoid

5. Zygomatic Bone
Maxillary
Palatine
• Zip - My - Pants
• Zygomatic
• Maxillary
• Palatine

6. • Great - Z
• Greater
Wing of
Sphenoid
• Zygomatic
Bone
Greater Wing of Sphenoidd
Bone
Zygomatic Bone

7. • Smel(1)
• Sphenoid
• Maxilla
• Ethmoid
• Lacrimal

10. A fibrous annulus that surrounds the optic canal and the medial
part of the superior orbital fissure; it gives origin to the four rectus
muscles of the eye and is partially fused with the sheath of the
optic nerve.

11. • Lacrimal nerve
• Frontal nerve
• Trochlear nerve
• SOV
• Superior division of III
• Inferior division of III
• Nasociliary nerve
• Abducent nerve

13. • Zygomatic Nerve (VII)
• Infra-orbital nerve
• Infra-orbital artery
• IOV
Structures passing through the IOF

15. • Vessels:
Ophthalmic artery
Ophthalmic veins
• Nerves:
Sensory: Lacrimal,
Frontal &
Nasociliary
(Branches of V1)
Motor: III, IV & VI

16. 1. Central Retinal Artery
2. Lacrimal Artery
3. Muscular Arteries
4. Short Posterior Ciliary Arteries
5. Long Posterior Ciliary Arteries
6. Supra-Orbital Artery
7. Supra-Trochlear Artery
8. Dorsal Nasal Artery
9. Anterior Ethmoidal Artery
10.Posterior Ethmoidal Artery

18. • A dural venous sinus on both sides of Sphenoid bone
• Contents:
1. Cavity: Internal carotid Artery, sympathetic fibers
2. Wall: III, IV, V1 & V2
• Communications

19. • Lid edema

20. • Conjunctival Chemosis

21. • Proptosis (Axial forward
Protrusion of the globe)
“Nafziger Test”
Looking from above
Bring Upper & Lower orbital
margins in the same plane
Look whether the cornea is
coming out of this plane

22. • Enophthalmos (Axial
Backward Retraction of
the globe)

23. • Dystopia (Displacement
of the globe in the
coronal plane)

24. • In 9 diagnostic positions of gaze

25. • Forced expiration against closed glottis
Before After

26. Pulsations (Thrill)
To detect
pulsation, cotton-
tipped applicators
are placed
tangentially
across closed
lids. Pulsation is
transmitted and
amplified by
length of stick

27. Orbital margin
Fingertip exploration 360°; palpation for
anterior aspect of orbital mass, or fracture.

28. Bruit
Auscultation of globe and face.
Top. Stethoscope bell used to auscultate
globe and orbit; note that contralateral eye
fixates finger to minimize lid movement.
Middle. Stethoscope diaphragm was used
to auscultate zygoma.
Bottom. Stethoscope diaphragm used to
auscultate temple. Vascular bruits may also
be best heard at the mastoid.

29. • Cornea: Exposure keratopathy

30. • IOP
measurement

31. ONH swelling
Opto-Ciliary
shunts
Optic atrophy
Choroidal
folds
• Fundus exam

32. • CT Orbit
• MRI Orbit
• Biopsy

33. Lid
Conjunctiva
Proptosis
Exophthalmos
Dystopia
In 9 diagnostic
positions
Pulsations (Thrill)
Orbital margin
Bruit
Cornea
IOP
Fundus exam
CT Orbit
MRI
Biopsy

34. The commonest cause
More in middle age, females
Exophthalmos
1. Orbital cellulitis
2. Mucormycosis
1. Idiopathic Ocular Inflammatory Disease (IOID)
2. Myositis
1. Varices
2. Carotid Cavernous Fistula (CCF)
3. Lymphangioma
1. Dermoid cyst
2. Sinus Mucocele
3. Encephalocele
1. Lacrimal Gland
2. Optic nerve & its sheaths
• Proptosis (Axial forward
Protrusion of the globe)

35. • Young; Dermoid cyst, Encephalocele, Lymphangioma,
Infection
• Elder; TED
• Old; Tumours
• CC
F
• Infection
• Inflammation
• DM; Mucormycosis
• Thyrotoxicosis

36. • Lid edema • Conjunctival Chemosis

37. “Nafziger Test” Pseudo-Proptosis

38. Assessment of the Severity of
Proptosis
Resting on the lateral orbital margin
• > 20 mm
indicates
proptosis
• > 2-3 mm
difference
between both
eyes is
suspicious
regardless the
absolute value

39. In case of limited ocular motility

41. • e.g. Orbital Varices, meningocele
Before After

42. Pulsations (Thrill)
• Pulsating Proptosis
1. CCF
2. Meningocele
3. Encephalocele

43. Bruit
Auscultation of globe and face.
Top. Stethoscope bell used to auscultate
globe and orbit; note that contralateral eye
fixates finger to minimize lid movement.
Middle. Stethoscope diaphragm was used
to auscultate zygoma.
Bottom. Stethoscope diaphragm used to
auscultate temple. Vascular bruits may also
be best heard at the mastoid.
1. CCF (Vascular) Bruit
2. Meningocele No Bruit
3. Encephalocele No Bruit

44. • Cornea: Exposure keratopathy
• IOP
measurement
• Fundus exam

45. • CT Orbit
• MRI Orbit
• Biopsy • Menigo-encephalocele• CCF

46. • The most common cause of both bilateral and unilateral proptosis in an adult.
• Graves disease, the most common form of hyperthyroidism, is an autoimmune disorder in
which IgG antibodies bind to thyroid stimulating hormone (TSH) receptors in the thyroid
gland and stimulate secretion of thyroid hormones.
• More common in females, Forth - Fifth decades.
Goitre
Clubbing
Pre-tibial myxedema
Nervous
Weight loss

47. • Organ-specific autoimmune
reaction in which an antibody
that reacts against thyroid
gland cells and orbital
fibroblasts
• Inflammation of extra ocular
muscles, interstitial tissues,
orbital fat and lacrimal glands
characterised by pleomorphic
cellular infiltration, associated
with increased secretion of
glycosaminoglycans and
osmotic imbibition of water.

48. • Subsequent degeneration of
muscle fibres eventually leads to
fibrosis, which exerts a tethering
effect on the involved muscle,
resulting in restrictive myopathy
and diplopia

49. Red eye
Lacrimation, photophobia
Puffy lid
Grittiness
Staring look
• Binocular Diplopia
• Impaired central vision
Exposure, PEE

50. • Lid edema
• Conjunctival chemosis, Congestion
• Lid Retraction (Dalrymple sign)
• Rim of sclera visible between
cornea & UL
• Due to contraction of Muller
muscle (Sympathetic)

51. • Lid Lag (von Graefe)• Starring look (Kocher sign)

52. • Moebius sign (Weak
convergence)
• Stellwag sign (Infrequent blinking)

53. • Joffroy sign (Absent of forehead corrugation on looking up)

54. Stellwag sign Infrequent blinking Eye lids stand still
Joffroy sign
Absent corrugation
of forehead on
looking up
Absent Frowning
Patient in Joy
Moebius sign Weak Convergence Weak Muscle Mobility
Dalrymple sign Lid Retraction
Visible Rim of sclera
between cornea & UL
von Graefe sign Lid Lag
Kocher sign Staring Look

55. “Nafziger Test”
• Proptosis is axial, unilateral or bilateral
• Symmetrical or asymmetrical
• Frequently permanent.
Assessment of the
Severity of Proptosis

56. • Ocular motility is restricted initially by inflammatory oedema, and later by fibrosis
• Defective elevation of the left eye
• Caused by fibrotic contracture of IR
• The most common motility deficit
• Defective abduction of the right eye
• Caused by fibrotic contracture of MR
• The 2nd most common motility deficit
Forced Duction Test

57. • Cornea: Exposure keratopathy
• IOP
measurement
• Fundus exam

58. • T3, T4, TSH
• Muscle belly
enlargement
with tendon
sparing
•For compressive
optic neuropathy

59. The first measure taken in all cases should be the cessation of
smoking.
Control of Thyrotoxicosis
• No Compressive Optic neuropathy
A. Lubricants for corneal exposure and dryness.
B. Topical anti-inflammatory agents (steroids, non-steroidal
anti-inflammatory drugs (NSAIDs), ciclosporin)
C. Head elevation with three pillows during sleep to reduce
periorbital oedema.
D. Eyelid taping during sleep may alleviate mild exposure
keratopathy.

60. • Compressive Optic neuropathy
A. Systemic Steroids: Oral Prednisolone, IV Methylprednisolone
B. Low dose Fractionated Radiotherapy; in addition to steroids or when steroids
fails (Complications: cataract, retinopathy, optic neuropathy)

61. • After Remission of Active Inflammation
• Proptosis: Orbit Decompression Surgery
1. One Wall Removal (Lateral wall)
2. Two Wall Removal (Medial & Lateral)
3. Three Wall Removal (Medial, Lateral & Floor)
4. Four Wall Removal (Medial, Lateral, Floor & Roof)
‫بالترتيب‬

62. • After Remission of Active Inflammation
• Angle of deviation is stable for 6 - 12 months
• Restrictive Myopathy :
For Persistent Diplopia
Surgery: Muscle Recession with Adjustable Sutures
‫بالترتيب‬

63. • After Remission of Active Inflammation
• Lid Retraction:
Botulinum toxin injection (Temporary)
Muller muscle Disinsertion (Mullerotomy)
‫بالترتيب‬
Before
After

64. Thyroid
Eye
Disease
Decompression
Squint
Lid
System of TED surgery
TED is DSL

65. • Acute Suppurative Inflammation
of orbital cellular tissue, behind
the orbital septum
- Para-nasal sinuses
- Endophthalmitis
- Panophthalmitis
- Dacryocystitis
- Preseptal cellulitis
- Dental infection
- Ocular Surgery; squint,
lid surgery
- Ocular trauma
- S. aureus
- S. pneumoniae
- S. pyogenes
- H. influenza
- Immunocompromised

66. • General: FAHM
• PAIN: exacerbated by eye movement
• VISION: impaired (ON compression or inflammation)
• SWELLING of the eye
• Recent HISTORY of sinusitis, …

67. • Lid edema
• Conjunctival chemosis, Congestion
• Proptosis or Dystopia
• Might be obscured by lid swelling

68. • Painful or restrictive ophthalmoplegia

69. • Cornea:
• IOP
measurement
might be difficult
• Fundus exam
Corneal Abscess
Exposure keratopathy
• Reduced VA • RAPD

70. Spread of Infection

71. Spread of Infection

72. • CT Orbit: Hyper-dense orbital shadow

73. Orbital Cellulitis
Cavernous
Sinus
Thrombosis
Thyroid Eye
Disease
Laterality Unilateral Bilateral
Unilateral or
Bilateral
VA Reduced
Severely
Diminished
Not affected in
early course
General FAHM Severe illness Thyrotoxicosis
Imaging
Hyper-dense orbital
tissues
Venous
Thrombosis
Enlarged EOM

74. • Hospital admission
• Systemic Antibiotics (Triple line)
Gm +ve e.g. Vancomycin
Gm -ve e.g. Ceftazidime
Anaerobe e.g. Metronidazole
• Monitor ON functions (every 4 hours at least)
VA
Pupil reactivity
Colour vision
Light Brightness Appreciation

75. Surgery
• Indications:
A. Sub-periosteal abscess
B. Infected Para-nasal sinus
C. Lack of response to medical therapy
D. ON compression
Drainage
Emergency Lateral Canthotomy

76. • Acute Suppurative Inflammation of orbital cellular tissue,
anterior to the orbital septum
- Acute Hordeolum
- Acute
Dacryocystitis
- Conjunctivitis
- Sinusitis
- Hematogenous
- Ocular Surgery; squint,
lid surgery
- Ocular trauma
- S. aureus
- S. pyogenes
- Immunocompromised

77. • General: FAHM
• PAIN: No relation to eye movement
• VISION: Not affected
• SWELLING of the lid
• Recent HISTORY of trauma, …

78. • Lid oedema, redness
• Conjunctiva NAD
• Normal

79. • Free
• No Abnormalities; VA,
IOP, pupil And fundus
are not affected
• How to know??

80. • CT Orbit: Hyper-dense shadow anterior
to the orbital septum

81. • Systemic Antibiotics
Oral e.g. Co-Amoxiclav
IV in severe infection

82. • Inflammation & Thrombosis of the
cavernous sinus
Spread from:
- Orbit
- Para-nasal sinuses
- Middle ear
- Face
- Contralateral
cavernous sinus
- Orbital infection,
Sinusitis, Otitis media, …
- S. aureus
- S. pyogenes
- Immunocompromised

83. • As Orbital Cellulitis with the following Differences:
A. Poor General Condition
B. Bilateral involvement
C. More severe symptoms & signs
D. Total Ophthalmoplegia(III, IV, VI)
E. Pupil dilatation (III)
F. Fundus shows ONH swelling with engorged veins (Defective venous drainage)
G. Oedema over the mastoid bone (Thrombosis of mastoid emissary vein,
Griesinger sign)

84. • Hospital admission
• Systemic Antibiotics (Triple line)
Gm +ve e.g. Vancomycin
Gm -ve e.g. Ceftazidime
Anaerobe e.g. Metronidazole
• Monitor ON functions (every 4 hours at least)
VA
Pupil reactivity
Colour vision
Light Brightness Appreciation
• Anticoagulants

85. • Proptosis
• Total ophthalmoplegia (III, IV & VI)
• Loss of corneal sensation (V1)
• Optic neuropathy (II)
• As Orbital Apex Syndrome except the Optic neuropathy

86. • Caused by sudden increase in the
orbital pressure from an impacting
object that is greater in diameter than
the orbital aperture (about 5 cm), such
as a fist or tennis ball.

87. • Lid oedema, Laceration
• Conjunctiva Chemosis

88. • +/- Enophthalmos

89. • Double Diplopia;
Restrictive limitation in ocular motility in UP & DOWN gaze (IR entrapment)
UPDown

90. Orbital margin
Fingertip exploration 360°; palpation for orbital
margin fracture.
• Infra-orbital
Anaesthesia

91. • CT Orbit: Tear drop sign

92. • Oral Antibiotics
• Nasal Decongestant, Ice packs
• Instruct patient NOT to blow his nose
• +/- systemic steroids, if compressive optic neuropathy
Indications • Fracture involving > 1/2 orbital floor
• Enophthalmos > 2mm
• Persistent Diplopia in 1ry position
When • Within 2 weeks of trauma

94. • Usually accompanies floor
fracture
• Subcutaneous emphysema
• Horizontal Double Diplopia
(MR entrapment)

95. • Rarely encountered by
ophthalmologists
• Might be associated with
other craniofacial fractures
• +/- pulsating proptosis (CSF)

96. • Rarely encountered by
ophthalmologists
• Usually associated with
extensive facial damage

97. • Iatrogenic; retrobulbar anaesthesia
• Trauma
• Spontaneous e.g. bleeding disorder

98. • Lid oedema
• Conjunctiva Chemosis, hematoma
• Proptosis
• Limitation
• High
• ONH swelling

99. • Compression
• IV mannitol 20% (to lower IOP)
• Oral Acetazolamide (to lower IOP)
Full thickness lateral canthus incision Full thickness lateral canthus incision
+ Transection of inferior crus of the
lateral canthal tendon

100. Congenital Anomaly of Normal tissue present in abnormal place
Contains tissues of ectodermal origin e.g. skin, hair, …

101. Empty socket
Removal of
ocular contents

102. • Removal of the
whole eye
• Intra-ocular tumour
• Sympathetic
ophthalmia

103. • Removal of the whole
orbital contents inclosed in
the periosteum + Eye lids
• Malignant tumours
invading the orbit

104. Failure of the conjunctival sac (Socket) to hold the artificial eye
• Infection
• Neglecting wear of the artificial eye for
long period
• Unsuitable artificial eye size
• Socket Reconstruction with mucous
membrane or skin graft after excision
of the scarred conjunctiva